Provider Demographics
NPI:1871710699
Name:WYNKOOP, JASON M (LCSW)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:WYNKOOP
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 S GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3431
Mailing Address - Country:US
Mailing Address - Phone:847-894-8116
Mailing Address - Fax:
Practice Address - Street 1:317 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3431
Practice Address - Country:US
Practice Address - Phone:847-894-8116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490113961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42636264Medicaid